Section by Section Guidance on January 1, 2023, Rate Study Increases

Jan 09, 2023

As detailed in the January 4, 2023, and December 30, 2022, notices, the Department has posted State Plan methodology notices detailing rate increases for Sections 13, 17, 26, 28, 65, and 92 on our State Plan Methodology page. The new rates will be effective retroactive to January 1, 2023.

This notice issues further service-specific guidance, including section-by-section timing for implementation of the new rates, any modifier and/or unit changes to services, billing instructions for services provided before the new rates are ready for billing in MIHMS, and further billing guidance as appropriate for certain services. Please reference the sections below as they pertain to your enrollment.

For references to providers adjusting their own claims, detailed instructions for claims adjustment can be found here.

As noted in previous messages, MaineCare will send additional messages as the claims system updates are completed for each section.

 

 

Section 13, Targeted Case Management Services

Implementation timing: The Department anticipates that Section 13 updates should be completed in MIHMS by 1/11/2023.

 

Billing options prior to implementation of new rates: Prior to receiving notification that MIHMS has been updated, providers may:

1. Bill claims using the new rate as identified on the State Plan Methodology page, and the Department will adjust claims on behalf of providers once MIHMS is updated; or
2. Hold claims until MIHMS is updated and bill the new rate at that time.

 

Note: If a provider has already submitted claims using the rates in effect prior to January 1, 2023, they will need to adjust their own claims once MIHMS is updated.

 

 

Section 17, Community Support Services

 

Implementation timing: The Department anticipates that Section 17 updates should be completed in MIHMS by 1/11/2023.

 

Services with unit changes to rates: The Department has made changes to the unit of service for Assertive Community Treatment (ACT) Services as follows:

 

Service	Old Unit	New Unit
Assertive Community Treatment (ACT)	Daily	Weekly

 

Billing options prior to implementation of new rates:

For all Section 17 services except for ACT, prior to receiving notification that MIHMS has been updated, providers may:

1. Bill claims to MaineCare using the new rate as identified on the State Plan Methodology page, and the Department will adjust claims on behalf of providers once MIHMS is updated; or
2. Hold claims until MIHMS is updated and bill the new rate at that time.

 

Note: If a provider has already submitted claims using the rates in effect prior to January 1, 2023, they will need to adjust their own claims once MIHMS is updated.

 

For ACT services only: Providers should hold their claims until they receive notification that MIHMS is updated and bill the new rate and unit at that time.

 

Additional billing guidance for ACT services:

For ACT services, all expectations included in the MaineCare Benefits Manual Chapter II, Section 17.04-3 continue to apply, including ensuring that the delivery of services meets the minimum standard of a calendar monthly average of three face-to-face contacts per week. This means that to bill the weekly unit, the provider should see the member and provide covered services on three separate days each week, or clearly document why the contacts did not occur as detailed in the rule.

 

Performance metrics and payment withholds will not begin until formal rulemaking has been adopted.

 

 

Section 26, Day Health Services

 

Implementation timing: The Department anticipates that Section 26 updates should be completed in MIHMS by 1/11/2023.

 

Billing options prior to implementation of new rates:

Prior to receiving notification that MIHMS has been updated, providers may:

1. Bill claims to MaineCare using the new rate as identified on the State Plan Methodology page, and the Department will adjust claims on behalf of providers once MIHMS is updated; or
2. Hold claims until MIHMS is updated and bill the new rate at that time.

 

Note: If a provider has already submitted claims using the rates in effect prior to January 1, 2023, they will need to adjust their own claims once MIHMS is updated.

 

 

Section 28, Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations

 

Implementation timing: The Department anticipates that Section 28 updates should be completed in MIHMS by 2/1/2023.

 

Services with modifier changes for rates:

There are modifier changes for all Section 28 services. New modifiers will:

1. Distinguish school-related from home and community Section 28 services, and
2. For school-related services, further differentiate billing practices by enrolled provider type. This is because schools are exempt from the Service Provider Tax (SPT), while non-school providers of Section 28 school-related services are subject to the SPT. Rates for schools therefore do not include payment to reimburse for the tax, while rates for other providers do include payment for the tax.  

 

Service	Old Mods	New Mods
Children’s Rehab and Community Support (H2021)
Home and Community (not school-related)	HQ HI	TJ HI
School-Related (for non-school providers)	HQ HI	TR HI
School-Related – SPT exempt (for school providers)	HQ HI	HI
Specialized Children’s Habilitative Services (H2021)
Specialized Home and Community (not school-related)	HQ HK	U1 HK
School-Related (for non-school providers)	HQ HK	U2 HK
School-Related – SPT exempt (for school providers)	HQ HK	HK
Children’s Rehab. And Community Support, BCBA (G9007)
BCBA School-Related – SPT exempt (name change, for school providers)	HA	HA
BCBA Services (Community Based Wrap Around)	HA	HA AF

Please review the more detailed rate descriptions and modifiers for Section 28 on the State Plan Methodology page carefully to ensure that you are billing the correct rate for your provider type and service location.

 

Billing options prior to implementation of new rates:

Prior to receiving notification that MIHMS has been updated, providers may:

1. Bill claims to MaineCare using the new rates and modifiers as identified on the State Plan Methodology page, and the Department will adjust claims on behalf of providers once MIHMS is updated. Please note that when claims are billed using the new modifier(s) the claims will initially deny: the claims will not pay until the Department adjusts the claims; or
2. Continue billing using rates and modifier conventions in effect prior to January 1, 2023, and providers will need to adjust their own claims to indicate the new rates and modifiers once MIHMS is updated; or
3. Hold claims until MIHMS is updated and bill the new rates and modifiers at that time.

 

Additional billing guidance for Section 28 services:

 

Board Certified Behavior Analyst (BCBA) and Specialized Services:

With the new Specialized Services rate models and consistent with the service description under MaineCare Benefits Manual Chapter II, Section 28.04-3, costs associated with the delivery of BCBA services are included in the Specialized Services rate model and no longer require separate BCBA billing in order to cover BCBA costs in the provision of Specialized Services. This is evident in the significant increase to the Specialized Services rates, using the H2021 HK code/modifier combination. Given this increase, the Department anticipates that providers will bill for a standalone BCBA service (G9007 HA) only in exceptional circumstances where the service was not part of a Specialized Service model.

           

As a reminder, providers should be billing claims for Individuals with Disabilities Education Act (IDEA) services using the correct TL and TM reporting modifiers as detailed in the May 17, 2022 provider notice.  These reporting modifiers are in addition to the modifiers identified on the State Plan Methodology page.

 

 

Section 65, Behavioral Health Services

 

Implementation timing: The Department anticipates that Section 65 updates should be completed in MIHMS by 2/1/2023.

 

Services with modifier and/or unit changes to rates:

 

Changes to the units of service:

Service	Old Unit	New Unit
Children’s Behavioral Health Day Treatment	Hourly	15-minute
Specialized Group Services	15-minute	Per session
Children’s HCT	15-minute	Weekly
Children’s ACT	Daily	Weekly
Triple P	15-minute	Per session
Incredible Years	15-minute	Per session

 

Changes to modifiers:

Outpatient Therapy and Comprehensive Assessment: Previously, modifiers designated agency versus independent practitioner. The new modifiers distinguish services by provider credential, community versus office setting, and group versus individual/family service. Providers should use the modifier for “Community” settings when the provider delivers the service outside of the office in a community setting, e.g. the member’s home, or a restaurant or outdoor space in the member’s community, as clinically indicated for the member. This table lists the new modifiers:

 

Service Setting	Office	Office	Community
Service Model	Ind/Fam	Group	Ind/Fam
Outpatient Individual/Family or Group Therapy (H0004)
Trauma-Focused Cognitive Behav. Therapy	ST	(n/a)	ST U1
Psychologist	AH	AH HQ	AH U1
LCSW/LCPC/LMFT	HO	HO HQ	HO U1
Deaf	(no mod)	(n/a)	U1
LADC	HN	HN HQ	HN U1
CADC	HM	HM HQ	HM U1
Outpatient Comprehensive Assessment (H2000)
Psychologist	AH	(n/a)	AH U1
LCSW/LCPC/LMFT	HO	(n/a)	HO U1
Deaf	(no mod)	(n/a)	U1
LADC	HN	(n/a)	HN U1
CADC	HM	(n/a)	HM U1

 

Specialized Group Services: The new modifiers vary by type of group specialized service. This table lists the new modifiers:

 

Service	Old Mod	New Mod (type of group service)
Specialized Group Services (H2019)
Wellness Recovery Action Planning (WRAP)	(n/a)	HH
Recovery Workbook Group	(n/a)	HE
Trauma Recovery and Empowerment Group (TREM)	(n/a)	ST
Dialectical Behavior Therapy (DBT)	(n/a)	HK

 

Children’s Home and Community Treatment: The new code and modifier combinations reflect the fact that service elements are now bundled into a weekly rate, so it is no longer necessary to distinguish billing based on the credential level of the provider or the provision of collateral contact, as was done previously. The new modifiers simply indicate when the weekly rate is for MaineCare-funded HCT, Office of Child and Family Services-funded HCT, or HCT services that utilize Trauma-focused Cognitive Behavioral Therapy.

 

Service	Old Code/Mod(s) (separate services)	New Code/Mod (bundled service model)
HCT (H2021/G9007)
HCT (MaineCare funded)	H2021 HO, H2021 HN, G9007 HO, G9007 HN	H2021 HA
HCT – (OCFS-Funded)	H2021 HU, H2021 HU U1, G9007 HU, G9007 HN	H2021 HU
HCT (TF-CBT)	H2021 ST, H2021 HN, G9007 HO, G9007 HN	H2021 ST

 

Behavioral Therapies for Disruptive Behavior Disorders (T1027): New modifiers differentiate rates based on the credential of the service provider.

 

Service	1:1	Group 2-4	Group 5-7	Group 8+
Triple P - Bachelor’s	HN HA	HN HA UN	HN HA UR	HN HA US
Triple P - Master’s	HO HA	HO HA UN	HO HA UR	HO HA US
Incredible Years	(n/a)	TJ UN	TJ UR	TJ US
Parent-Child Interaction Therapy (PCT)	HA	(n/a)	(n/a)	(n/a)

 

Billing options prior to implementation of new rates:

For services WITHOUT any changes to modifiers and/or units:

Prior to receiving notification that MIHMS has been updated, providers may choose to:

1. Bill claims to MaineCare using the new rates as identified on the State Plan Methodology page, and the Department will adjust claims on behalf of providers once MIHMS is updated; or
2. Hold claims until MIHMS is updated and bill the new rate and modifiers at that time.

 

Note: If a provider has already submitted claims using the rates, modifiers and/or units in effect prior to January 1, 2023, they will need to adjust their own claims once MIHMS is updated.

 

For services WITH changes to modifier and/or unit (see tables above):

Prior to receiving notification that MIHMS has been updated, providers may:

1. Bill claims to MaineCare using the new rates and/or modifiers as identified on the State Plan Methodology page, and the Department will adjust claims on behalf of providers once MIHMS is updated. Please note that when claims are billed using the new modifier(s) and/or unit(s) the claims will initially deny: the claims will not pay until the Department adjusts the claims; or
2. Bill claims to MaineCare using rates, modifier(s), and/or unit(s) in effect prior to January 1, 2023, and providers will need to adjust their own claims to indicate the new rates and units of service once MIHMS is updated; or
3. Hold claims until MIHMS is updated and bill the new rate, modifier(s), and/or unit(s) at that time.

 

Additional billing guidance for Section 65 services:

 

For Children’s ACT services, all expectations included in the MaineCare Benefits Manual Chapter II, Section 65.08 continue to apply. Additionally, to ensure delivery of services in fidelity to the ACT model, providers should aim for a minimum of a calendar monthly average of three face-to-face contacts per week. This means that to bill the weekly unit, the provider should see the member and provide covered services on three separate days each week, or provide an explanation of why this did not occur.

 

For HCT services, all expectations included in the MaineCare Benefits Manual Chapter II, Section 65.09 continue to apply. Additionally, providers should aim for a monthly average of three face-to-face or telehealth contacts per week, of which at least one contact per week is a clinical intervention with the clinician. Qualifying contacts are interventions provided by a treatment team member (clinician and/or BHP), which directly address the youth’s identified treatment goals and may include collateral contacts as defined in Section 65.05-10.

.  

 

Performance metrics and payment withholds will not begin until formal rulemaking has been adopted.

 

Note: HCT clinician-only services do not qualify for the new weekly rate. Instead, clinicians delivering services in the home may seek reimbursement under the new Outpatient Community rate.

 

We would also like to remind providers that they should be billing claims for Individuals with Disabilities Education Act (IDEA) services using the correct TL and TM reporting modifiers as detailed in the May 17, 2022 provider notice.  These reporting modifiers are in addition to the modifiers identified on the State Plan Methodology page.

 

 

Section 92, Behavioral Health Home (BHH) Services

 

Implementation timing and billing guidance: BHH providers will be able to and should attest for BHH services as normal through the VMS portal for services provided between December 21, 2022, and January 20, 2023.

 

Your increased reimbursement will show when you receive your payment for that month.

 

New performance metrics and payment withholds will not begin until formal rulemaking has been adopted.

 

 

 

For questions regarding any of these changes or guidance, please contact your Provider Relations Specialist.